IRB Concussion Guidelines En

7/30/2019 IRB Concussion Guidelines En

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Summary Principles

Concussion must be taken extremely seriously to safeguard the long term welfare of Players.

Players suspected of having concussion must be removed from play and must not resume

play in the match.

Players suspected of having concussion must be medically assessed.

Players suspected of having concussion or diagnosed with concussion must go through a

graduated return to play protocol (GRTP).

Players must receive medical clearance before returning to play.

Introduction

The IRB takes Player Welfare seriously and played a central role in the development of the

Zurich Consensus (2008) on Concussion in Sport on which these guidelines are based. The

guidelines were designed to be used by physicians and other health professionals as well as

team management, teachers, parents and Players. The guidelines are meant to ensure that

Players who suffer concussion are managed effectively to protect their long term health and

welfare. Scientific knowledge in the field of concussion is constantly evolving and the

consensus process will make sure that the IRB guidelines will keep pace with these changes.

What is Concussion?

Concussion is a complex process caused by trauma that transmits force to the brain either

directly or indirectly and results in temporary impairment of brain function. Its development and

resolution are rapid and spontaneous. A Player can sustain a concussion without losing

consciousness. Concussion is associated with a graded set of clinical signs and symptoms

that resolve sequentially. Concussion reflects a functional rather than structural injury and

standard neuro-imaging is typically normal.

CONCUSSION MUST BE TAKEN EXTREMELY SERIOUSLY.

INTERNATIONAL RUGBY BOARDPutting players first

IRB Concussion Guidelines


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INTERNATIONAL RUGBY BOARD Putting players first


Concussion producing forces are common in Rugby; fortunately most of these do not result inconcussion. There is widespread variation in the initial effects of concussion. Recovery is

spontaneous often with rapid resolution of signs, symptoms and changes in cognition (minutes

to days). This could increase the potential for Players to ignore concussion symptoms at the

time of injury or return to play prior to the full recovery from a diagnosed concussion. This may

result in a more serious brain injury or a prolonged recovery period. The potential for serious

and prolonged injury emphasizes the need for comprehensive medical assessment and follow-

up until the concussion has fully resolved. Returning to play before complete resolution of the

concussion exposes the Player to recurrent concussions that might take place with ever

decreasing forces. We have concerns that repeat concussion could shorten a Players career

and may have some potential to result in permanent neurological impairment. Players must be

honest with themselves and medical staff for their own protection.

What are the signs of Concussion?

The common signs and symptoms indicating that a Player may have concussion are listed

below in Table 1. If a Player shows any of the signs described in the Table (as a result of a

direct blow to the head, face, neck or elsewhere on the body with a force being transmitted to

the head) they have suspected concussion.

Table 1: Common early signs and symptoms of concussion

Indicator Evidence

Symptoms Headache, dizziness, feeling in a fog

Physical signs

Loss of consciousness, vacant expression, vomiting, inappropriate

playing behaviour, unsteady on legs, slowed reactions

Behavioural changes Inappropriate emotions, irritability, feeling nervous or anxious

Cognitive impairment

Slowed reaction times, confusion/disorientation, poor attention

and concentration, loss of memory for events up to and/or after

the concussion

Sleep disturbance Drowsiness


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Stage 1: Diagnosis and Management of Concussion

What happens if a Player is injured and has suspected concussion?

Diagram 1 below indicates what should happen if a Player has suspected concussion. It

addresses the situation both when a Medical Practitioner and/or Healthcare Professional is

present and not present. If a Player is suspected of having concussion that Player must be

removed from play and must not resume playing in the match.

Medical Practitioner and/or Healthcare Professional present

Where an injury event with the potential to cause a head injury or concussion occurs and there

is a Medical Practitioner or Healthcare Professional present the Player will be examined and if

any of the signs or symptoms in Table 1 are identified and/or the Player fails to answer correctly

the five memory questions in Pocket Scat 2 (Appendix 2) the Player MUST be removed from the

field of play for a comprehensive medical evaluation. An assessment of the Players balance is

likely to form part of this off-field evaluation. The Player MUST NOT resume play once removed

from the field for suspected concussion.

Memory questions:

At what venue are we today?

Which half is it now?

Who scored last in this game?

Which team did you play last week/game?

Did your team win the last game?

The Player must be removed in a safe manner in accordance with emergency management

procedures. If a cervical spine injury is suspected the Player should only be removed by

emergency Healthcare Professionals with appropriate spinal care training.

If a Medical Practitioner is present they can use SCAT 2 (Appendix 1) or other diagnostic tools

to assist in the comprehensive medical evaluation of Players with concussion or suspected

concussion. Note that SCAT2 must only be used for Players aged from 10 years and older.

Medical practitioners can familiarise themselves with SCAT 2 using the IRB online training

programme, available through www.irbplayerwelfare.com planned for release in Autumn 2011.

A Player suspected of having concussion shall move to Stage 2, the GRTP protocol,

irrespective of the subsequent diagnosis.


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Medical Practitioner and/or Healthcare Professional not present

If there is no Medical Practitioner or Healthcare Professional present the Player who is injured

may be disorientated and unable to make a judgement about their own condition. Fellow

Players, coaches, Match Officials, team managers, administrators or parents who observe an

injured Player displaying any of the signs in Table 1 after an injury event with the potential to

cause a head injury or concussion MUST do their best to ensure that the Player is removed

from the field of play in a safe manner.

The Player must not be left on his or her own and must not be allowed to drive a vehicle. If a

medical practitioner is not available on-site the Player must be referred to a medical practitioner

for diagnosis and comprehensive assessment as soon as possible.

Pocket SCAT 2 (Appendix 2) can be used to assist in the identification of suspected

concussion where a medical practitioner is not present at the time of the incident. Most

importantly if a Player:

a. Shows any of the listed symptoms in Table 1; or

b. Fails to answer any of the memory questions correctly in Pocket SCAT 2; or

c. Makes more than five errors in the balance test in Pocket SCAT 2 ; or

d. There are any concerns that the Player is suspected of having concussion;

then concussion must be suspected and the Player must be removed from play and referred toa Medical Practitioner or Emergency Department for diagnosis and comprehensive assessment

as soon as possible.

A Player suspected of having concussion shall move to Stage 2, the GRTP protocol,

irrespective of the diagnosis.

Pocket SCAT 2 is available from www.irbplayerwelfare.com . It is recommended that coaches,

team managers, administrators, teachers, parents, Players, Match Officials and Healthcare

Professionals associated with Rugby teams educate themselves in the use of Pocket SCAT 2

using the IRB online training programme available through www.irbplayerwelfare.com planned

for release in Autumn 2011.

Onset of Symptoms

It should be noted that the symptoms of concussion can first present at any time (but typically

in the first 24 48 hours) after the incident which caused the suspected concussion.


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Diagram 1

Stage 1: Diagnosis and initial management

INJURY EVENT

Move to Stage 2

Graduated Return to Play

irrespective of diagnosisof actual concussion

Player diagnosed and

further assessed

using SCAT2

Refer to Medical

Practitioner or Emergency

Department for diagnosis

and further assessment

Medical Practitioner

present

On-pitch / sideline

assessment AND player

has an injury with

suspected concussion

Player MUST be removed

from the field of play and

MUST NOT play any further

part in the game




part in the game




part in the game

On-pitch / sideline


has an injury with


On-pitch / sideline


has an injury with


No Medical

Practitioner present

Healthcare

Professional present


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Modifying Factors in Diagnosis and Management of Concussion

Modifying factors are those that may influence the investigation and management of

concussion including the GRTP. In some cases they may predict the potential for prolonged or

persistent symptoms (Table 2).

Table 2: Concussion Modifiers

Factors Modifier

Symptoms

Number

Duration (>10 days)

Severity

SignsProlonged loss of consciousness (>1 min)

Amnesia

Sequelae Concussive convulsions

TemporalFrequency repeated concussions over timeTiming injuries close together in time

Recency recent concussion or traumatic brain injury

ThresholdRepeated concussions occurring with progressively less Impact

force or slower recovery after each successive concussion

Age Child (


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Children and adolescents

Whilst the guidelines apply to all age groups particular care needs to be taken with children and

adolescents due to the potential dangers associated with concussion in the developing brain.

Children under ten years of age may display different concussion symptoms and should be

assessed by a Medical Practitioner using diagnostic tools. As for adults, children (under 10

years) and adolescents (10 18 years) with suspected concussion MUST be referred to a

Medical Practitioner immediately. Additionally, they may need specialist medical assessment.

The Medical Practitioner responsible for the childs or adolescents treatment will advise on the

return to play process, however, a more conservative GRTP approach is recommended. It is

appropriate to extend the amount of time of asymptomatic rest and /or the length of the graded

exertion in children and adolescents.

Children and adolescents must not return to play without clearance from a Medical

Practitioner.

Stage 2: Graduated Return to Play (GRTP)

Following a concussion or suspected concussion how does the Player return toplay?

Following a concussion or suspected concussion the management of a GRTP should be

undertaken on a case by case basis and with the full cooperation of the Player. This will be

dependent on the time in which symptoms are resolved. It is important that concussion is

managed so that there is physical and cognitive rest until there are no remaining symptoms.

Activities that require concentration and attention should be avoided until symptoms have been

absent for a minimum of 24 consecutive hours without medication that may mask the

symptoms e.g. headache tablets, anti-depressant medication, sleeping medication, caffeine.

The modifying factors in Table 2 should also be taken into consideration. The GRTP process

which is managed by a Medical Practitioner is shown in Diagram 2.

When GRTP is managed by a Medical Practitioner

If a Medical Practitioner (with the assistance of a Healthcare Professional, as applicable) is

managing the recovery of the Player it is possible for the Player to return to play after a

minimum of six days having successfully followed and completed each stage of the GRTP

protocol. The Medical Practitioner may observe the Player at each stage of the GRTP protocol

but may also delegate the observation to a Healthcare Professional while remaining responsible

for the management of the protocol. The GRTP applies to all situations including tournaments.

An indicative minimum GRTP protocol is provided in Table 3. Provided that the Player with

concussion or suspected concussion is, and remains, symptom free the Player may commence

the GRTP.


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Before a Player can restart exercise they must be symptom free for a period of 24 hours (Level1) and then they may move to the next stage (Level 2). Under the GRTP protocol, the Player

can proceed to the next stage if no symptoms of concussion (SCAT 2 provides the symptom

checklist) are shown at the current stage (that is, both the periods of rest and exercise during

that 24-hour period). This includes level 1 where the Player must experience a minimum of 24

consecutive symptom-free hours of rest prior to moving on to Level 2.

Where the Player completes each stage successfully without any symptoms the Player would

take approximately one week to proceed through the full rehabilitation protocol. If any

symptoms occur while progressing through the GRTP protocol, the Player must return to the

previous stage and attempt to progress again after a minimum 24-hour period of rest has

passed without the appearance of any symptoms.

After Level 4 the Player resumes full contact practice and the Medical Practitioner and the Player

must first confirm that the Player can take part. Full contact practice equates to return to play for

the purposes of concussion. However return to play itself shall not occur until Level 6 (Table 3).

Table 3: GRTP Protocol

Rehabilitation stage

Functional exercise at each stage

of rehabilitation

Objective of each

stage

1. No activity, minimum 24 hours

following the injury where managed

by a medical practitioner, otherwise

minimum 14 days following the injury

Complete physical and cognitive rest

without symptomsRecovery

2. Light aerobic exercise during 24-hour

period

Walking, swimming or stationary

cycling keeping intensity,


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Diagram 2

Stage 2: GraduatedReturn to Play

For those where theGRTP protocol ismanaged by aMedical Practitioner

Medical Practitioner to manage process

Does player have any symptoms remaining

after no activity over a 24 hour period?

Player has no symptoms

remaining after no activity

over 24 hour period - Level 1

Light aerobic exercise -

Level 2

Rest until

symptom free

No recurrence

of symptoms

within 24 hours

No recurrence

of symptomswithin 24 hours

Recurrence of

symptoms - 24 hoursrest

Symptom free Symptom(s) present

Rugby-specific exercise - no

head contact (running drills)

Level 3

No recurrence

of symptoms

within 24 hours

Recurrence of

symptoms - 24 hours

rest

Non-contact training skills

(passing and resistancetraining) Level 4

No recurrence


Recurrence of


Medical Practitioner and

player agree that player may

participate in full contact

practice Level 5

No recurrence

of symptoms

within 24 hours

Recurrence of

symptoms - 24 hours

rest

There can be a return to play - level 6


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Where GRTP is NOT managed by a Medical Practitioner

There may be extreme situations where a Player does not have access to a Medical Practitioner

to diagnose concussion or to manage the GRTP. In these situations if a Player has shown signs

of concussion that Player must be treated as having suspected concussion and must not play

until at least the 21st day after the incident and should follow the GRTP process outlined in

Diagram 3. Other Players, coaches and administrators associated with the Player should insist

on the guidelines being followed.

If a Player has been diagnosed with concussion by a Medical Practitioner but does not have

access to a Medical Practitioner to manage the GRTP that Player must not play until at least the

21st day after the incident and should follow the GRTP process outlined in Diagram 3.

In the above situations the GRTP process may commence after a 14 day stand-down period

from playing sport and/or training for sport and only if there are no symptoms of concussion.

Ideally the process should be managed and observed by someone familiar with the Player who

could identify any abnormal signs displayed by the Player. Pocket SCAT 2 will assist the person

managing the process.

Before a Player can restart exercise they must be symptom free for a period of 14 days (Level 1)

and then they may move to the next stage (Level 2). Under the GRTP protocol, the Player canproceed to the next stage only if no symptoms of concussion (SCAT 2 provides the symptom

checklist) are shown at the current stage (that is, both the periods of rest and exercise during

that 24-hour period).

Where the Player completes each stage successfully without any symptoms the Player would

take approximately one week to proceed through the full rehabilitation protocol from Level 1. If

any symptoms occur while going through the GRTP protocol, the Player must return to the

previous stage at which he/she did not experience any symptoms and attempt to progress

again after a minimum 24-hour period of rest has passed without the reappearance of any

symptoms.

After Level 4 the Player resumes full contact practice and the Medical Practitioner and the Player

must confirm that the Player can take part. Full contact practice equates to return to play for the

purposes of concussion. However return to play itself shall not occur until Level 6 (Table 3).

Clearance to return to play by a Medical Practitioner should always be sought. However, there

may be occasions (which will be in extreme and rare situations) where a Player cannot access a

Medical Practitioner to assess the Player for clearance to resume full contact practice. In these

extreme and rare situations the Union having jurisdiction over the Player must put in place

processes and mechanisms which will only permit Players to resume full contact practice when

it is safe to do so. These processes and mechanisms may vary from Union to Union.

Adolescents and children must have clearance from a Medical Practitioner before they can

return to play.


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Diagram 3

Stage 2:Graduated Return

to Play

For those wherethe GRTPprotocol is notmanaged by a

MedicalPractitioner

GRTP monitored by a third party after 14

days of no playing of or training for sport

Does player have any symptoms remaining after

14 days of no playing of, or training for, sport?

Player has no symptoms

remaining after no activity -

Level 1

Rest until

symptom free

No recurrence

of symptoms

within 24 hours

No recurrence


Recurrence of


Symptom free Symptom(s) present

Rugby-specific exercise - no

head contact (running drills)

Level 3

Not before day 16

No recurrence

of symptoms

within 24 hours

Recurrence of

symptoms - 24 hours

rest

Non-contact training skills

(passing and resistance

training) Level 4

Not before day 17

No recurrence


Recurrence of


Medical Practitioner and

player agree that player may

participate in full contact

practice Level 5

Not before day 20

No recurrence

of symptoms

within 24 hours

Recurrence of

symptoms - 24 hours

rest

There can be a return to play - level 6

Not before day 21

Light aerobic exercise -

Level 2Not before day 15


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It is recognised that Players will want to return to play as soon as possible following aconcussion. Players, coaches, management, parents and teachers must exercise caution to:

a. Ensure that all symptoms have subsided;

b. Ensure that the GRTP protocol is followed; and

c. Ensure that the advice of Medical Practitioners (and where applicable Healthcare

Professionals) is strictly adhered to.

In doing so, all concerned can reduce the risk to a Players career longevity and long term

health.

All involved in the process of concussion management (including those mentioned above) must

be vigilant for the return of symptoms (including depression and other mental health issues)after a concussive incident even if the GRTP has been successfully completed. If symptoms re-

occur the Player must consult a Medical Practitioner and those involved in the process of

concussion management and/or aware of the return of symptoms should do all they can to

ensure that the Player consults a Medical Practitioner as soon as possible.

Definitions

GRTP means graduated return to play.

Healthcare Professional means an appropriately-qualified and practising physiotherapist,

nurse, osteopath, chiropractor, paramedic, athletic trainer (North America) who has been trainedin the identification of concussion symptoms and the management of a concussed Player.

Medical Practitioner means a doctor of medicine.

Player means a player of the Game who is a non-contract Player or a contract Player.

IRB Concussion Guidelines Issued 24 May 2011

International Rugby Board

IRB Concussion Guidelines En

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